Imperial Care Center

In the surveyor’s words

From the most serious findings on record at Imperial Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF600Mar 20, 2024

  Based on observation, interview, and record review, the facility failed to protect the residents ' rights to be free from neglect (a form of abuse where the perpetrator, who is responsible for caring for persons unable to care for themselves, fails to do so) and physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) inflicted by another resident for six of 11 sampled residents (Residents 8, 1, 2, 9, 11, and 10). The facility failed to: 1. Ensure Residents 8, 1, 2, 9, 11, and 10, who were confused, were assessed as a high fall risk, had wandering behavior (moving around without any clear purpose or direction) and history of falls, were provided with supervision, redirection, and monitoring of their whereabouts. 2. […]

• Immediate jeopardy, patternF689Mar 20, 2024

  Based on observation, interview, and record review, the facility failed to prevent falls and injury for six of 11 sampled residents (Residents 8, 1, 2, 9, 11, and 10), who were confused and were identified as high risk for falls and risk for elopement (a confused person leaving the facility unnoticed by staff and does not return, it is the most dangerous type of unsupervised wandering [moving about aimlessly or without a specific purpose]). The facility failed to: 1. Ensure Residents 8, 1, 2, 9, 11, and 10, were assessed as a high fall risk, had wandering behavior (moving around without any clear purpose or direction) and history of falls, were provided with supervision, redirection, and monitoring of their whereabouts. 2. […]

• Immediate jeopardy, isolatedF689Apr 27, 2025

  Based on observation, interview, and record review, the facility failed to provide supervision (refers to the ongoing monitoring and guidance provided by staff to ensure the safety and well-being of a resident) to one of three sampled residents (Resident 1), who was cognitively impaired (refers to difficulties with thinking, learning, remembering, and using judgment, among other mental abilities) and was admitted to a secured facility (specialized healthcare setting that restricts patient movement and access to promote safety with measures such as locked doors and surveillance). […]

• Immediate jeopardy, isolatedF600May 10, 2024

  Based on interview and record review, the facility failed to follow its abuse policies and procedures (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, and Abuse & Mistreatment of Residents, to protect one of three sampled residents (Resident 1) from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) by failing to: 1. Ensure Certified Nursing Assistant 1 (CNA 1) received abuse training. 2. Ensure CNA 1 did not hit (slap and punch) Resident 1. As a result, on 5/1/2024 at 5:30 p.m., Student Nurse 1 (SN 1) walked in Resident 1 ' s room and witnessed CNA 1 slapping and punching Resident 1 in Resident 1 ' s arms and back. […]

• Immediate jeopardy, isolatedF600Mar 17, 2022

  Based on interview and record review, the facility failed to ensure one of nine sampled residents (Resident 1), who was nonverbal, had severely impaired cognition (mental process of thinking and understanding), and totally dependent on staff for care was kept free from sexual abuse. Facility staff found Certified Nursing Assistant 1 (CNA 1) behind closed curtains with Resident 1. CNA 1 had his pants and underwear down to his ankles while standing in between Resident 1 ' s legs and holding her legs up with his hands. […]